FOR OLDER ADULTS, delirium is a life-threatening disorder and a serious public health concern. It's been linked to an additional 15-day hospital length of stay, an estimated $4 to $16 billion increase in costs, and a mortality of 19% within 6 months.1 Delirium affects up to 80% of critically ill patients, but it often goes unrecognized.2 Due to the serious sequelae of delirium, the dangerous adverse reactions to medications used to treat it, and its high incidence in critically ill patients, nurses must be able to identify delirium early with the Confusion Assessment Method-Intensive Care Unit (CAM-ICU) tool and use viable nonpharmacologic interventions at the bedside.3,4
This descriptive study was an undergraduate honors project in response to an educational initiative on delirium and nonpharmacologic interventions. Its purpose was to discover the interventions critical care nurses at a Level I trauma center in northeastern Pennsylvania were already applying in practice.
Reviewing the literature
The survey was created from an expansive review of the literature that covered many nonpharmacologic interventions, including music therapy and an appropriate day-night rotation to help patients distinguish night from day, as discussed below. Although studies of music therapy are limited and more research is needed, the evidence of its benefits is already convincing. Music therapy decreases anxiety in patients, provides physiologic benefits after 30 minutes of treatment, leads to a decrease in sedative use in intubated patients, and decreases surgical pain when used intraoperatively and postoperatively.5-8 Anxiety, sedative use, and pain exacerbate or prolong delirium, so using music to lessen them can decrease the time that patients experience delirium as well as improve overall outcomes.
A day-night rotation strategy is essential to prevent delirium or decrease the time the patient is delirious. Patel and colleagues implemented a multidisciplinary intervention involving eight champions who focused on reducing noise at night, providing appropriate light and darkness in patient rooms, and reducing middle-of-the-night sleep interruptions. These interventions reduced the average time a patient was delirious from 3.4 days to 1.2 days.9
Another study looked at cortisol and melatonin levels and found that nonpharmacologic interventions targeting sleep lowered patients' cortisol levels and increased their melatonin levels. The researchers also found that the intervention group spent significantly fewer days delirious.10
Recommendations from the Society of Critical Care Medicine's clinical practice guidelines for delirium in the ICU include day-night rotation strategies in addition to early mobility. Early mobility lowers the prevalence of delirium, decreases length of stay, and permits earlier weaning from mechanical ventilation.11
Although the guidelines support the evidence for nonpharmacologic bundles for non-ICU patients, more research is required to develop a nonpharmacologic bundle for ICU patients.11
Surveying critical care nurses
After obtaining an institutional review board exemption to survey employees of the institution, we created a 30-question survey from the review of the literature that focused on questions investigating knowledge of delirium, use of the CAM-ICU tool, and nonpharmacologic interventions used in practice. One hundred and twenty nurses received the survey and 39 responded, resulting in a 32% response rate from the target population. Most respondents were female (82%) and worked full-time (65%), with about half (46%) of the respondents working day shift and most of the others (46%) working night shift.
Results
After completing demographic questions, respondents were asked about their use of the CAM-ICU tool. They then addressed questions about different types of delirium. The open-ended question about the gold standard tool for assessing delirium was correctly identified as CAM-ICU by 76.9% of respondents. Fewer (44.7%) said that they consistently used the tool in practice. When asked about the most common form of delirium, four respondents (11.1%) correctly identified hypoactive delirium.11 When presented with a case study depicting hypoactive delirium, 18 respondents (48.7%) correctly identified it. In contrast, a question about the signs and symptoms of hyperactive delirium (select all that apply) was correctly identified by 89.5% of respondents.
The next section asked respondents about nonpharmacologic interventions and specific questions about music therapy. Respondents were asked an open-ended question about the interventions they currently use in practice (see Five most common interventions used in practice). In accord with the Society of Critical Care Medicine's guidelines, 23 respondents (59.5%) identified optimal day-night rotation, and 3 respondents mentioned early mobility.11 Fifteen respondents (40.5%) got their ideas for nonpharmacologic interventions from the literature or in-hospital education, and 35 (92.1%) said they'd be interested in further education on the topic.
The final section asked respondents three music therapy questions. Thirty-four respondents (94%) correctly identified classical music as the best genre for music therapy, while 16 (44%) correctly chose a time frame of 1 hour as the best length of time for a music therapy session with a patient.6,12 When asked a question (select all that apply) about the positive effects of music therapy, 76.3% of respondents correctly chose that it reduced anxiety, lowered pain intensity levels, and decreased the dosage of sedation medication needed.12
Implications for practice
Given the serious outcomes of unrecognized and untreated delirium, it's essential for clinical nurses to be educated and empowered to implement nonpharmacologic interventions to prevent delirium. Thirty-five respondents (92.1%) from the survey were interested in more in-hospital education on the topic. Annual education, investigating the literature, and the tools to implement these nonpharmacologic interventions could empower nurses to optimize patient outcomes for this serious disorder.
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